There is a strong emphasis on evidence-based practice in teaching
health students and it underpins much health research [1,2]. Many
emphasize ‘patient centred care’ combining research evidence, patient
context and clinical wisdom into evidence-based patient choice where
(ideally) practitioners and patients jointly consider evidence, decisions
and recommendations [1,3-6]. Simultaneously, there is increasing call
to work with patients and to respect patient choice [3,7]. But what is the
outcome when these two principles clash? What happens when a new
mother tells a midwife that “I don’t want to breastfeed, I want my body
back”, or when an overweight diabetes patient tells a slim dietician that
“I can’t be bothered monitoring what I eat; I feel ok most of the time”
or when a patient suffering hypertension tells his/her doctor “I don’t
want to take pills”. What happens when evidence and patient choice
directly, or even more subtly, clash? The midwife, the dietician and the
doctor may take a breath and tell themselves and the patient that they
respect patient wishes, they may share information for consideration,
but their face and their body language reflect their own commitment to
their ‘expert’ knowledge as to what could be best. Because of this, some
patients will not share their views for fear of being judged negatively;
rather they keep their opinions to themselves and endure the label of
‘non-compliance’. Patient choice is difficult to practice.

Without going to the decision-making ‘place’ of the patient, the
information from and recommendations of health professionals are
less likely to be adopted. It is time discussion moved toward providing
strategies for busy health professionals to sincerely integrate patient
choice and consumer perspectives into their practice. Integrating
the triad of research evidence, patient context and clinical wisdom
effectively takes time—time to listen to the patient, inform the patient
of recent evidence and to jointly discuss diagnosis, treatment and
other related issues. It also takes a practitioner who is flexible, open,
genuine, reflective and has well developed listening skills. But are
health care professionals trained adequately in these skills? And even if they are, culture, the social determinants of health, communication
skills and other barriers remain. Practitioners have a commitment to
their disciplinary knowledge that they have trained in for multiple
years which is hard for them to reject. Haynes et al. acknowledge this
conundrum: “providing evidence to patients in a way that allows them
to make an informed choice is challenging and in many cases beyond
our current knowledge of doctor-patient communication—very much
a problem awaiting the generation of new evidence [4].” It is time we
addressed this complexity to improve health outcomes for patients
most likely to disengage from health services.

Abandoning years of professional training in the face of “I can’t
be bothered” may not be possible. But involving patients, sharing
information and making joint decisions can overcome many of these
problems [1,4]. There remains times when evidence and choice clash.
Being prepared for these times is a requirement of good practice—
acknowledging and discussing them is a starting point.